27 NSAIDs

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1 - Approximate time required: 60 min. 

Educational Goal:

To provide Adult Foster Care providers with information that will help them understand and utilize the Non-steroidal Anti-inflammatory Drug class of medication.

Educational Objectives:

  1. List the NSAIDs
  2. Instruct about how NSAIDs work
  3. Explain about the side effects of NSAIDs
  4. Inform about caregiver issues effecting NSAID use

Procedure:           

  1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

Disclaimer      

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

27 NSAIDs

    Did you know that there were 27 different drugs in the NSAID class of medications? That doesn’t include combination drugs, so the number of NSAID-containing meds is actually much higher.  NSAID stands for Non-Steroidal Anti-Inflammatory Drug. They are among the most commonly used drugs for pain killing in the world today (aspirin is included in this group).  They can be used to kill pain, reduce fever, and reduce swelling due to inflammation.  Many find NSAIDs have advantages other painkillers do not. NSAIDs are not addicting like narcotics, and they reduce inflammation (acetaminophen and opiates do not), which helps in the healing process.

 

List of NSAIDs

Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin)

Choline and magnesium salicylates (CMT, Tricosal, Trilisate)

Choline salicylate (Arthropan)

Celecoxib (Celebrex)

Diclofenac potassium (Cataflam)

Diclofenac sodium (Voltaren, Voltaren XR)

Diclofenac sodium with misoprostol (Arthrotec)

Diflunisal (Dolobid)

Etodolac (Lodine, Lodine XL)

Fenoprofen calcium (Nalfon)

Flurbiprofen (Ansaid)

Ibuprofen (Advil, Motrin, Motrin IB, Nuprin)

Indomethacin (Indocin, Indocin SR)

Ketoprofen (Actron, Orudis, Orudis KT, Oruvail)

Magnesium salicylate (Arthritab, Bayer Select, Doan's Pills, Magan, Mobidin, Mobogesic)

Meclofenamate sodium (Meclomen)

Mefenamic acid (Ponstel)

Meloxicam (Mobic)

Nabumetone (Relafen)

Naproxen (Naprosyn, Naprelan*)

Naproxen sodium (Aleve, Anaprox)

Oxaprozin (Daypro)

Piroxicam (Feldene)

Salsalate (Amigesic, Anaflex 750, Disalcid, Marthritic, Mono-Gesic, Salflex, Salsitab)

Sodium salicylate (various generics)

Sulindac (Clinoril)

Tolmetin sodium (Tolectin)

     NSAID use accounts for a major portion of both prescription and over-the counter pain-relieving efforts in modern medicine. But lately there has been some bad press about the harmful effects of NSAIDs. In fact, the FDA recently issued new consumer alerts and required manufacturers to increase their warning labels on all NSAID products sold in the United States.  So what’s the deal? Are they safe or unsafe to use? This CE course will answer some of those questions. 

 

How NSAIDs Work

    To truly understand NSAIDs, you must first start with what pain is. Pain is a very complex subject. For a greater understanding, see my other CEs. At its simplest, pain is the brain’s warning system that damage is being done to the body. When the cells in the body are harmed or ruptured, certain chemicals are released into the surrounding area. They in turn trigger other cells that release additional triggering chemicals that start a cascade of protecting reaction from the body. Nerve signals are sent to the brain; swelling starts to wall off of the damaged area, and fever sometimes start to occur as an additional warning signal and as a protection to kill off certain heat-sensitive opportunistic infections.  This is an over-simplification of a complex reaction that is still not fully understood. The important thing to remember is this is a chemical cascade reaction, like a domino chain that branches out to trigger specific responses from the body.

    Narcotics and acetaminophen block the reaction farther down the domino chain closer to the brain. NSAIDs block the domino chain closer to its start by inhibiting an enzyme called the cyclooxygenase or Cox for short. That’s how NSAIDs reduce inflammation while other painkillers do not.  So far we have identified two types of Cox enzymes, Cox1 and Cox2. They are responsible for converting arachadonic acid into prostaglandins. Prostaglandins, in turn, branch out to warning signals, protective mechanisms, and restorative healing processes pathways. 

Nsaids

    Some of you might be thinking “Whoa up there, partner, you’re getting’ a bit deep for me!”  You’re probably right.  I did get a little pharmacologically carried away there.   So let’s ratchet it back a bit and just say NSAIDs stop prostaglandin from being produced, which in turn leads to the desired effects and some undesired side effects.

 

Side Effects

    There are multiple kinds of prostaglandins used throughout the body for various purposes. If you reduce the production of prostaglandins, naturally you’ll affect all the processes they are involved with. As a result, NSAID use could lead to side effects. To be clear, not all NSAIDs’ side effects are tied to prostaglandins and not all are well understood.  The most common side effects, though, are connected to the prostaglandins or the cox enzymes.

 

GI Tract Side Effects

     The gastrointestinal (GI) tract dissolves the food we eat with a soup of powerful enzymes and acids. What keeps this combination from dissolving the GI tract lining is a mucus layer that insulates us from our digestive juices. As you can imagine, that mucous layer has to be constantly replaced. Unfortunately for NSAID users, prostaglandins play a major role in renewing of the protective mucous layer. If the protective process is disrupted long enough, ulcers appear, which lead to bleeding into the GI tract.

     Several of the NSAIDs are week acids themselves, which only compounds the problem.  Drug manufacturers have tried to reduce this problem by coating their product (enteric coated aspirin) or adding buffers that help balance the acidic effect (buffered aspirin).  These help the acid problem, but the reduced prostaglandin problem still remains.

    Fortunately for most NSAID users, significant GI problems never develop if directions are followed. Under normal conditions, prostaglandin production is continuously being turned on and off as the body needs them in a process called homeostasis.  So the body can handle short-term or minor interruption in prostaglandin production.  Where GI problems occur the most is with prolonged use or higher doses of NSAIDs. That is one reason that OTC NSAIDs warn never to exceed 10 days of therapy without consulting a doctor.

     There is one NSAID that is different than all the rest. Celecoxib (Celebrex) primarily affects only the Cox2 enzyme. This enables Celebrex to avoid most of the serious GI tract problems that are rooted in the blockage of the Cox1 enzyme.  Unfortunately blocking only the Cox2 enzyme leads to possible cardiovascular side effects.

 

Cardiovascular Side Effectssleep4

     A less common but more serious side effect of NSAID use involves how prostaglandins are used by the body in the cardiovascular system.   There are Cox1 enzymes located in blood cells called platelets. They are involved in the beginning of the blood clotting process.  Cox2 enzymes are found in the lining of blood vessel walls and are involved in unsticking platelets (reduces clotting) and relaxing or dilating blood vessels, which drops blood pressure.  If you start messing around with blood clotting or blood pressure, seriously bad things can happen. NSAID use could lead to heart attack, stroke, high blood pressure, kidney problems, liver problems, and anemia.

     It is important to note that some of these side effects aren’t always a problem. Sometimes side effects can actually be used to help a patient. Low-dose aspirin prevents blood clotting and can be used to prevent strokes and heart attacks.

 

Allergy and Breathing Problems

     In my pharmacy career, I have found that you can find someone who is allergic to just about anything. Those who are allergic to NSAIDs have an over-reactive protection response of inflammation when NSAID are taken.  If they have serious swelling in their lungs, life- threatening breathing problems can occur.  This reaction is of particular concern to asthma suffers or others who already have breathing problems. It turns out that approximately 10 to 20 percent of adults with asthma have sensitivity to aspirin or other NSAIDs. Those numbers lead many doctors to say that all asthma sufferers should not take NSAIDs because you can never tell when an allergy will start to develop.

 

Other Side Effects Concerns

     Each drug has its own side effect profile, and it is up to the care provider to read the warning literature that comes with each bottle. Other side effects that could occur include:

  • Diarrhea
  • Vomiting
  • Dizziness
  • Drowsiness
  • Tinnitus (ringing in the ears)
  • Constipation
  • Gas

     You might be starting to freak out about now, saying, “I’ll never touch an NSAID again.” Time for a reality check. The vast major of NSAID users will never develop any serious health problems. You have taken an aspirin or ibuprofen yourself in the past and lived to tell the tale. Even the FDA still allows for NSAIDs to be sold to anyone OTC (over the counter). If you follow the directions and are aware of the warning signs, no major problems will likely occur.

     But people don’t always follow instructions and read the warnings, not even health professionals. That has led the FDA to require prominently placed warnings on NSAID containers called black box warnings. They also require pharmacists to hand out an extra Medication Guide with all NSAID prescriptions.  In essence, the FDA is saying that really serious problems can occur so pay attention when using NSAIDs.

 MP900442656

Caregiver Issues

Paying Attention

     Speaking of paying attention, that’s your job as a caregiver. Pay attention to the drug info provided with each drug. Pay attention to how the drug is supposed to act.  Pay attention to the side effects that can occur.  What it really boils down to is knowing what the normal condition is for your residents and taking note of any changes that occur when they take their medicine.

According to the FDA’s Medication Guide that is supposed to be handed out with each prescription, NSAID caregivers should watch for the following warning symptoms.

  • Nausea
  • More tired or weaker than usual
  • Itching
  • Skin or eyes look yellow
  • Stomach pain
  • Flu-like symptoms
  • Vomit blood
  • Blood in bowel movement or it is black and sticky like tar
  • Unusual weight gain
  • Skin rash or blisters with fever
  • Swelling of the arms and legs, hands, and feet

Stop your NSAID medicine and call your healthcare provider right away if you have any of the following symptoms.

 

Staying Alert

     One of the major challenges of any medical practice today is how can any care provider keep an alert watch on the important details when they are repeated over and over and over again. It is a natural human tendency to ignore repetitive tasks that don’t change.  It happens to doctors, pharmacists, nurses, and it will happen to you.

Here are a couple of facts about NSAID use that might help you keep alert to your patients’ safety.

  1. Doctors and pharmacists are human, too, and they can bypass important details. Don’t assume that everything will be OK just because the drug has passed through the hands of a doctor and pharmacist.
  2. Many of the serious side effects of NSAIDs are more likely to occur after prolonged use. It will take a while to overwhelm the homeostatic mechanisms of the body. That means that initially there would not be any side effects. They are more likely to develop down the road just when you are starting to ignore the possibility because nothing has happened at the start of therapy.
  3. Allergies can develop at any time even after years of NSAID use. It is less likely, but it has been known to happen.
  4. Mild allergic reactions will most likely progress to more serious reactions the more the resident is exposed to the drug they have a reaction to. That means that minor allergy-caused side effects will probably not stay minor with continued use of the offending drug. The major problems you want to watch for will happen down the road, just when your mind is starting to get bored of the task of paying attention.

 

Pregnancy and Breast Feeding

     To be complete in this article about warnings, some NSAIDs can cross the placental barrier and enter into breast milk. Interfering with the Cox enzymes of a baby can cause serious issues. NSAID medicines should not be used by pregnant women late in their pregnancy, and mothers should consult with their doctor or pharmacist about NSAID use while breastfeeding, even OTC NSAIDs.

 

Herbals

     Some herbal products contain NSAID or NSAID-like chemicals. Not all herbals are well studied, and we just don’t know all the details yet. The smart thing to do is if the herbal says it’s for pain relief- monitor it like an NSAID.

 

Conclusion

     Modern medicine has found the pain-relieving, fever-reducing, and anti-inflammatory effects of NSAID are so useful that it has developed and marketed over 27 different kinds.  Non-Steroidal Anti-Inflammatory medications are so common that caregivers will probably deal with them one way or another every single day of their foster care career.  Even so, NSAID use is so common the FDA has warned that serious sometimes life-threatening events can occur. Caregivers should note that the more their residents use NSAIDs, the more likely these ill effects can occur. That makes continued vigilant monitoring all that more important to keep clients healthy and happy.

As always, good luck in your caregiving

Mark Parkinson RPh

References:

1. Nonsteroidal anti-inflammatory drug. Wikipedia the Free Encyclopedia. Sep. 25 2015 https://en.wikipedia.org/wiki/Nonsteroidal_anti-inflammatory_drug

2. NSAID (List of non-steroidal anti-inflammatories) http://cdn.dupagemedicalgroup.com/userfiles/file/patientForms/nsaid-list.pdf

3. R. Morgan Griffin, Pain Relief: How NSAIDs Work. Arthritis Health Center, WebMD http://www.webmd.com/arthritis/features/pain-relief-how-nsaids-work  

4. Non-Steroidal Anti-Inflammatory Drugs (NSAID)-Oral MedicineNet http://www.medicinenet.com/nonsteroidal_anti-inflammatory_drugs_nsaid/article.htm      `

5. FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. U.S. Food and Drug Administration Jul 9 2015

http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm

6. Medication Guide for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) U.S. Food and Drug Administration. August 2007 www.fda.gov/downloads/Drugs/DrugSafety/ucm089162.pdf

7. NSAIDs and Cardiovascular Risk Explained, According to Studies from the Perelman School of Medicine. Penn Medicine, University of Pennsylvania Health System. May 2 2012 www.uphs.upenn.edu/news/News_Releases/2012/05/risk

 

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